Workshop ADHD and Mania: What should you know? Why should you care? Gabrielle A. Carlson, M.D.

Professor of Psychiatry and Pediatrics Director, Child and Adolescent Psychiatry Stony Brook University School of Medicine

Part 1 of 2

Disclosure – 2011

Company BMS GSK FIU

Research Support/ Honoraria/SAB Research Research This presentation

What I will talk about • ADHD- a quick summary of phenomenology, course and treatment • Bipolar disorder – a quick summary of phenomenology, course and treatment • Why has there been confusion; is mood dysregulation another word for bipolar • What are the treatment implications • What is needed to adequately assess mania/bipolar disorder

What ADHD is • ADHD is a heterogeneous, clinical condition • It comes in mild, moderate, severe forms • “Deficit” does not mean “None”. It means that attention cannot be sustained when the child or adult is not interested. • Think of H-I-D-E; Hyperactivity, Impulsivity, Distractibility/Disorganization-Emotional lability that is Persistent, Pervasive, imPairing • It often co-occurs with oppositional defiant/conduct disorder, mood and anxiety disorders, learning and language disorders

“Hyperkinetic Child Syndrome”Laufer and Denhoff, 1957

SYMPTOM

DESCRIPTOR

DSM IV ADHD

Hyperactivity

Involuntary and constant overactivity that greatly surpasses normal

YES

Poor Concentration

Frequent shifting from one activity to another

YES

Variability

Behavior is unpredictable. "Sometimes he is good, sometimes bad"

NO

Irritability/ Explosiveness

Fits of anger easily provoked ; reactions almost volcanic in intensity

NO

Impulsiveness

Does things on the spur of the moment. Cannot delay gratification

YES

Sleep disturbance

Falls asleep at proper time but wakens after only a few hours "rampaging through the house in hyperactive, noisy, sleepdisturbing play"

NO

G. Carlson, 2009

H-I-D-E (ADHD) Developmentally inappropriate levels of: Hyperactivity (6/9 sx): fidgets with hands or feet or squirms in seat; leaves seat in classroom inappropriately; runs about or climbs excessively; has difficulty playing quietly; is “on the go” or “driven by a motor”; talks excessively

Impulsivity: blurts out answers before questions are completed; has difficulty awaiting turn; interrupts or intrudes on others

Distractibility (6/9 sx): fails to give close attention to details; difficulty sustaining attention; does not seem to listen; does not follow through on instructions; difficulty organizing tasks or activities; avoids tasks requiring sustained mental effort; loses things necessary for tasks; easily distracted; forgetful in daily activities

Emotionality (associated symptom): Low frustration tolerance; sensitive to criticism; over-reactive, unpredictable shift toward negative emotion

The “E” has been given various names over the years – similar though not the same • • • • • • •

Negative affect Affective aggression Impulsive aggression Emotional or mood lability Emotional Impulsiveness Severe Mood Dysregulation “manic symptoms” [mania criteria without episodes]

Co-Occurring Disorders in MTA Children (n=579)

ADHD alone

Oppositional Defiant Disorder

Tic Dis. Conduct Disorder

Mood Dis. Anxiety Disorder

Course of the Disorder Inattention Though less than in childhood, it is still greater than In non-ADHD peers; verbal > physical Less than in childhood; more often verbal and cognitive than non-ADHD same age peers

—Age—

Outcome of ADHD

"Developmental Delay" - about 30% outgrow the disorder by young adulthood (symptoms minimal; Ability to compensate)* milder disorder

"Continual Display" - about 40% remain symptomatic with functional impairment *Worse hyperactivity/inattention---> poor academics

"Developmental Decay" - development of more serious antisocial and/or substance use disorders * * * *

Irritable temperament----> AGGRESSION Worse executive function-------> WORSE IMPULSIVITY Worse social adjustment----> WORSE PEERS More family psychopathology---> higher gene load + Less involvement and poorer communication; high level of fighting/domestic violence; poor supervision and monitoring.

Meta-analysis of 29 controlled studies over 25 years, encompassing 4465 children, adolescents) with some added information

Drug Amphetamine Methylphenidate Atomoxetine Guanfacine ER Clonidine Modafinil Bupropion Diet without additives

Effect Size 0.92 0.80 0.73 0.73 0.58* 0.49 0.32 0.2

Faraone SV, Spencer TJ: Presented at: American Psychiatric Association Annual Meeting, Toronto, Canada, May 2006. * Connor et al., JAACAP, 1999

MTA: % “Normalized” at 14 Months 100%

88%

80%

68% 56%

60% 34%

40%

25%

20%

0% Controls

Comb

MedMgt

Beh

CC

Comb = medical management + behavioral treatment; MedMgt = medical management; Beh = behavioral treatment; CC = community comparison group

Jensen PS, et al. J Dev Behav Pediatr. 2001;22:60-73.

Effect of severity on ADHD Mild

Moderate

Severe

When obvious

Elementary school

preschool

Age > mania % manic sample symptoms

measure

% Mania

10

250 teens, Columbia, Mo. 1

DICA

.06

5.7

1700 teens, OADP 2

K-SADS

.1

43

3329 6-12 y.o.s LAMS 3

GBI/KSADS

12.5

25

911 5-18 y.o. SB OPD 4

CMRS